Official SealDepartment of Budget and Management


#19-004239-0002
Supplemental Questionnaire

Last Name
First Name
1

Describe your experience with kidney dialysis services, including preparation, operation and maintenance.

Please include name of employer, job title, dates of employment, and hours worked per week, this information must also be reflected in your application.  If you do not possess experience in this area, put N/A in the box below. 

2

Do you possess a certificate as a Certified Nursing Assistant - Dialysis Technician (CNA-DT)?  If yes, please upload copy of certification to application.

Yes No

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